Chapter 7: Discussion and Conclusions
7.5 Occupational Adaption: A Complex Process
The successful outcome of a vocational rehabilitation programme, obtaining employment requires an individual to reconstruct their occupational identity. This reconstruction of occupational identity is termed occupational adaptation in occupational therapy theory and occupational science (Kielhofner et al. 2009; Walder & Molineux 2017)).
Occupational adaption is a lifelong process experienced by everyone throughout life as we interact with our environments. Occupational adaptation is an ongoing process of change (O’Brien and Kielhofner 2017) to achieve desired occupational goals, requiring traits of resilience. Resilience allows necessary adjustments to engage and adjust in new roles until a new sense of identity is formed (Greene 2014). The drive for change may vary over time, dependent on internal and external factors (O’Brien and Kielhofner 2017). Sustaining the drive for change requires us to repeat new ways of being over time. Through repetition, a newly organised identity is formed (O’Brien and Kielhofner 2017). A sense of occupational competence in this new identity is gradually formed (deLasHeras et al. 2017). In the absence of a productive life role, practice and reparation of a working role is not possible - so sustaining a drive for change to achieve occupational adaption is challenging.
In the absence of successful goal attainment, hopelessness and negative feelings may impact on motivation for change (Walder & Molineux 2017), and a willingness to determine current circumstances as acceptable may emerge. Maintaining current identity may provide a sense of security and familiarity (Walder & Molineux 2017).
7.5.1 Predictive WRI items; time to goal attainment
Individuals rated as ‘supports’ on ‘adapts routines to minimize difficulties’ take longer to obtain employment. The definition of ‘adapts routines to minimize difficulties’ is: ‘How the person has managed use of time, routine, and habits since the injury or since being out of work’. Criteria used to positively rate this item are ‘successfully (or some success) adapts to changing circumstances, adapts routine well, actively seeks to overcome difficulties since being ill/or out of work’ (Braveman et al. 2005).
Individuals rated as ‘interferes’ on ‘influence of other roles’ take longer to obtain employment. The definition of ‘influence of other roles’ is: ‘How much other roles in the client’s life influence his/her return to work’. The criteria used to negatively rate this item is ‘other roles (significantly) interfere with return to/ finding, keeping work, and seriously conflict with work role’ (Braveman et al. 2005).
In the context of having been out of work for a prolonged length of time, adapting routines to minimise difficulties may be accomplished by establishing a range of life roles unrelated to employment or education. This could be recognised as successful occupational adaption: forming an occupational identity which is somewhat satisfying. Maintaining motivation to move beyond the safety and security offered by established identity may be more challenging for individuals who have achieved this level of occupational adaptation, compared to those with an absence of alternative life roles, for whom difficulties in managing time, routines and habits persist.
7.5.2 Occupational Adaptation an Ongoing Process
Occupational therapists working with clients need to maintain their awareness that occupational adaptation is a lifelong dynamic process (Taylor 2017). Reappraisal can be supported by a process of developing competence, identity and supporting motivation for change (Walder & Molineux 2017). In VRS with people with complex mental health problems, opposing factors to maintaining motivation for change have been identified. Fear of failure and frustrations at the time involved job-searching, particularly when this is unsuccessful (Kinn et al. 2014). This is compounded when time spent in unsuccessful job hunting is interfering with life roles perceived as more successful (Kinn et al. 2014). It is understandable therefore how these factors may diminish motivation. Prolonged unemployment, even when motivation is high, can result in lowered self-efficacy and doubts about capacity for employment (Mettävainio & Ahlgren 2004).
A qualitative meta-synthesis (Kinn et al. 2014) identified how challenging the phase of seeking work may be. Using the analogy of ice-skating and hence, fear of falling, getting off the bench onto the ice to seek work requires confidence that may vary over time. They recommend that therapists must have insight into these challenges, offer empathy, and remain focused on the individual’s original motivations for change (Kinn
et al. 2014). Corbiere et al (2011) suggest practical support in job searching and preparatory behaviours may help maintain motivation.
Some researchers recommend that this is where providing sheltered workshops or day centres may have some value, allowing the establishment of work-focused routines (Argentzell & Eklund 2013). However, there are inherent risks in getting stuck in simulated worker roles. Previous studies have found simulated activities lacked challenge; they may lead to boredom, and the unintended consequence of diminishing confidence to seek out greater challenges (Prior et al. 2013). These segregated environments also limit regular social contact to others in the same situation, who do not act as role models in open employment or education (Argentzell & Eklund 2013; Prior et al. 2013; Kirsh 2016).
7.5.3 Personal recovery
There are similarities between the concept of occupational adaptation in occupational therapy literature and the concept of personal recovery:
‘A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles … to live a satisfying, hopeful and contributing life even with the limitations caused by illness’ (Anthony 1993).
Employment is recognised by many as central to the concept of personal recovery (Markowitz 2001; Boardman et al. 2003; Morrow et al. 2009), and is frequently a recovery goal for individuals with CMHPs (Noyes et al. 2018).
Gammelgaard et al. (2017) investigated how IPS and employment may influence recovery. They characterised successful attainment of employment as achieving five elements of personal recovery: Connectedness, Hope, Identity, Meaning and Purpose in Life, and Empowerment (CHIME) (Leamy et al. 2011). Employment provided connectedness with society and professionals in the VRS. Hopes included aspirations in employment, which offers opportunities beyond work in social life and leisure pursuits. They found that identities changed before employment and identity as a job seeker and valued individual. Meaning and purpose were extended by participating in job seeking and imagined in a new identity. And personal responsibility for job seeking promoted feelings for empowerment (Gammelgaard et al. 2017).
Mechanisms for maintaining this sense of connectedness, hope, identity, meaning and empowerment over a prolonged length of time in an IPS programme warrant further research.
7.5.4 Occupational Adaptation and aspirations for recovery
Findings of this study has recognised the challenge of maintaining drive for change in the dynamic process of occupational adaption. Goals to attain employment take longer when individuals have established satistifying roles and routines in other aspects of life. It is feasible that the large population of people with CMHP who have considered vocational goals and therefore have not engaged with IPS have simply not been supported to reappraise their identities and may hold beliefs that they are not capable of being successful in employment or education. Self-stigmatisation as a barrier to achieving vocational goals is well established (Provencher et al 2002; Hielscher et al 2017) Occupational therapist work across mental health services and have the opportunity to intervene early, promoting employment or education as a realistic goal (Noyes et al. 2018; Read et al 2018) ; instilling hope and extending aspirations in personal recovery journeys. OTs delivering IPS services should recognise the fluctuating nature of occupational adaptation and work to sustain beliefs that successful attainment of vocational goals is realistic. Recent studies have investigated the role of internships in open employment with some success (Sveinsdottir et al. 2014; Sveinsdottir & Bond 2017; Carmona et al. 2018). In contrast to segregated environments, internships provide real experience, the chance to practice new routines and form a new identity. The open employment environment also offers opportunities for developing new social networks with role models in employment, instilling hope and connectedness.